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Once again, the ongoing debate about if and when to prescribe statins for cholesterol reduction has hit the news, and probably created more confusion than ever. This time the headlines are about statin guidelines for teens and young adults, an age group for which it is particularly hard to reach consensus due to lack of long-term studies.

They concluded that 483,500 more young people in this age group with elevated low-density lipoprotein cholesterol (LDL-C) would be treated with statins if pediatric guidelines were used, compared with only 78,200 under the adult guidelines.

The pediatric guidelines recommend screening for lipid levels in everyone aged 17 to 21 years, and then prescribing statins for those who have LDL-C levels of at least 190 milligrams/deciliter without other risk factors, or at least 130 or 160 mg/dL when other risk factors are present. (Risk factors include hypertension, smoking, and obesity.) In contrast, the adult guidelines recommend statin treatment for people younger than age 40 only if LDL-C levels are at least 190 mg/dL.

So What’s Right When It Comes to Statins?

The study authors say, given the conflicting guidelines, that shared decision-making between doctor and patient is in order after discussion of the potential harms and benefits and the patient’s preferences for treatment.

While I am a strong supporter and practitioner of shared decision-making, I say good luck finding a doctor (except one with a special expertise in lipids and cardiac prevention) who understands that high cholesterol, independent of other risk factors, is a very poor predictor of future heart problems. And good luck finding a young adult, with or without a parent in tow, who begins to understand the risks and benefits of statins well enough to have a productive patient-doctor discussion.

Who Really Needs Cholesterol Testing?

While it is true that atherosclerosis can begin in young adulthood, and even far earlier, the fact is, plaque buildup is a very slow, lifelong process and it’s not going to cause heart problems until much later in life, with few exceptions.

That’s why I would not recommend doing cholesterol testing (or atherosclerosis screening tests like carotid ultrasound, imaging of the descending aorta, or a heart scan for coronary calcium if the imaging tests show thickening) until an individual reaches his or her mid to late twenties or even early thirties. The exception is in those with a strong family history of heart disease at early ages —meaning in the twenties, thirties, or forties.

If cholesterol is found to be very high in a young adult with family history (over 190 mg/dL), then they need to see a lipid specialist. Seeing a specialist is also particularly important if a young person is found to have either heterozygous or homozygous familial hypercholesterolemia, a genetic disorder characterized by very high levels of total and LDL cholesterol. In such rare cases, starting aggressive treatment early is essential.

Why Create Unnecessary Worry With Statins?

In my practice, I tell parents who’ve learned from a pediatrician that their teenager has high cholesterol (and where there’s no family history of early heart disease) that by the time their child is in his or her late twenties or early thirties, we’re going to have better genetic testing and better imaging of the arteries of the heart, which will tell if a person is really at risk. We will also have better treatments to arrest the slow buildup of atherosclerosis in its tracks.

Unless I am confident that a young person really is at high risk and that starting statin treatment at such a young age is absolutely necessary to prevent a future heart attack, I would be reluctant to do so.

Why put teens or young adults on a statin early, when long-term use in such age groups has not been tested?

Why label a teenager with a “disease” that can cause unnecessary anxiety?

Why give a young athlete a statin drug that might affect muscle strength?

Why trouble a 17-year-old with facts about statins and pregnancy and the potential for birth defects and the consequent need for abstinence or birth control?

Smoking and Diabetes Are Bigger Threats

To prevent early heart attacks, doctors need to tell teens and young adults to stop smoking and/or experimenting with cocaine and other stimulant drugs. Both smoking and drug use are far more likely to cause a heart attack in a young person than high cholesterol, especially when there’s family history of heart disease.

Doctors also need to pay more attention to treating prediabetes in the young. Both smoking and diabetes lead not just to heart disease but to cancer and many other health problems, which can hurt both quality of life and longevity. If a child is overweight and has belly fat, and there’s a family history of diabetes, then testing for high blood sugar is far more important than testing for high cholesterol. Lifestyle changes can prevent diabetes, but they won’t have much of an effect, if any, on lowering cholesterol.

In summary, I don’t think a pediatrician, or any doctor who’s not a preventive cardiologist or lipid specialist, should place a teenager or young adult on a statin, period. If there is known family risk, see a specialist to handle it.

Arthur Agatston, MD, is a cardiologist, medical director of Wellness and Prevention for Baptist Health South Florida, and clinical professor of medicine at Florida International University Herbert Wertheim College of Medicine in Miami. A pioneer in cardiac prevention, Dr. Agatston worked with Warren Janowitz, MD, on development of the Agatston Score (also called the calcium score), a method of screening for coronary calcium as an indicator of atherosclerosis. Agatston is well known as the author of the best-selling book The South Beach Diet. He maintains a cardiology practice and research foundation in Miami Beach.

Important: The views and opinions expressed in this article are those of the author and not Everyday Health. See More

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